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									2007 Skin Safety Class
1. History on Pressure Ulcers
2. Prevention
3. Communication
4. Treatment Options
5. Competency
Pressure Ulcers:
   2003: Adverse Health Care Event Reporting Law
    went into effect.
   Dec 6, 2004: Full reporting of events was expected.
   1st year data:
       #1: Foreign objects left in pts
       #2: Stage 3-4 pressure ulcers
   2nd year data:
       #1: Stage 3-4 pressure ulcers
   3rd year data:
       #1: Stage 3-4 pressure ulcers
Joint Commission
   Standards for Long Term Care
       FAQs for the 2006 National Patient Safety
        Goals for Long Term Care (Updated 2/06)
            Goal 14 (Pressure ulcer prevention)
            [New—14A] How should staff assess the
             risk of a resident developing a pressure
            [New—14A] What are some actions staff
             can take to prevent pressure ulcers in
             high risk residents?
   More coming for acute care hospitals
Public Advocacy Groups
Pressure Ulcers are “mostly” Preventable

    Prevention is the key!!
    1.   Know what causes pressure ulcers
    2.   Know the patient’s risks
    3.   Provide prevention interventions
    4.   Communication of interventions
    5.   Treatment plans
    MN Alliance of Patient Safety
    (MAPS) Advice to Hospitals:
   November 10, 2005
   Pressure Ulcer Prevention Summit

   Recommendations:
       ICSI Guidelines on Pressure Ulcers
       Health Care Protocols on Risk Assessment
        and Prevention
       Skin Care Teams
    Vision of a Skin Team
   Energetic leaders:
        Beth Kaiser Schafer, MS, RN
             Director of Professional Practice
        Mary Murphy, MA, RN
             Accreditation Coordinator
   Literature review of best practice for skin care.
   Review ICSI recommendations.
   Review NDNQI recommendations.
   Who is setting standard now?
        Partner with plastic surgeons
        Separate burns and surgical incisions
   Create education for the team.
   Get leadership support.
   Invite the right players to the team.
        Must have an interest or passion!
Skin Safety Team Begins 12/9/05
   Team Members:
   Physicians
   Administrative sponsor
   Clinical Educators
   Nutrition
   Director of PT/OT
   Nursing Managers
   Nursing Head Nurses
   Performance Improvement
   Respiratory Therapy
   Many staff nurses
   Ad hoc: Product manager
   Ad hoc: Electronic Medical Records staff member
Skin Safety Team Begins 12/9/05
   Team Members:
   Dr. Andrew Kiragu, Pediatrics
   Dr. John Bower, Knapp Rehab
   Beth Schafer, Administration
   Mary Murphy, CE Float Pool
   Barb Gale, CE Pediatrics
   Ann Kallinger, CE 5 Medicine
   Sallie Konruff, Nutrition
   Ruth Gromek, PT/OT
   Laura Miller, Nurse Mgr, MICU
   Terri Peterson, Head Nurse, MICU
   Karen Hoybook, PI
   Tomi Berntsen, Respiratory
Skin Safety Team Begins 12/9/05
   Team Members:
   Pat Anderson, Staff RN, Burn
   Sheri Wacha, Staff RN, Ortho
   Sarah Chown, Staff RN, STN
   Alicia Decker, Staff RN, SICU
   Scott Church, Staff RN, SICU
   Dan Rogich, Staff RN, MICU
   Darrel Waltz, Staff RN, 5 Med
   Ad Hoc:
      Mary Peloquin, EMR

      Sue Winkler, Product Manager
Member Education (Dec-Feb)
   1st HCMC Skin Team Meeting 12/9/06

   All members attended skin class
       Class is based on best practice and ICSI
   Focused on
       Risk assessments
       Prevention strategies
       Language of wounds
       Standardized treatment strategies
   Standardized assessments
Skin Safety Team Deliverables
   Establish baseline data.
   Reduce the incidence of skin pressure ulcers by 20%.
   Assess the knowledge base of the staff and reassess
    after six months.
   Submit ongoing data to the NDNQI beginning in the
    first quarter of 2006.
   Assist in standardizing skin care across the
   Determine cost savings related to improved care
   Take a leading role in the standardizing of language
    for documentation in the (EHR).
              Results (2006)
                                       Pressure Ulcers

# of ulcers

              40                                                           Stage 1
              30                                                           Stage 2
              20                                                           Stage 3
                   Feb   March April   May   July   Aug    Sept      Oct

                           57% reduction hospital wide
                           75% reduction in stage 2 ulcers on SICU
Class Objectives
   Define a pressure ulcer
   List four underlying causes associated with pressure
   Describe the standard for completing a skin risk
   Identify interventions use in preventing pressure
   Describe a proper skin inspection.
   Identify language for documentation of a wound
   Define the stages for classifying pressure ulcers.
   Describe appropriate products for wound treatment.
What is a Pressure Ulcer?
   Localized areas of tissue destruction caused
      by compression of soft tissue over bony
      prominence and an external surface for
             prolonged period of time.
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

 Pressure is created when the external surface
    against the skin and the person’s skeleton
   compress soft tissue sufficiently to interrupt
              circulation to the skin.

  When circulation is interrupted long enough,
    tissue ischemia and tissue death occur.
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

 The amount of pressure necessary to compress
    capillaries and interrupt circulation varies.

  Patients with disease processes, injury, those
       requiring vasopressors, or those with
   conditions resulting in impaired oxygenation
    or perfusion will require less pressure to
   create tissue ischemia, thus are more at risk.
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture
 Shear is the interaction of gravity and friction
  causing twisting or kinking of blood vessels.

Rather than completely interrupting blood flow,
    shear diminishes circulation to tissue and
     damages both tissue and blood vessel

Shear occurs when the skeleton moves, but the
   skin remains fixed to an external surface.
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

          Examples of Shear:
        Pulling patient up in bed
 Patient in Fowler’s position who slides
                down in bed
  Slide patient from bed to stretcher.
Shear and Friction
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

  Friction contributes to pressure ulcer formation
        by damaging the skin at the epidermal-
     dermal interface, the basement membrane.

    Friction ulcers are generally superficial and
       easily reversed, unless the cause is not
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

          Examples of Friction:
Heels and elbows which aid in movement for
             bedridden patients.
  Agitated patients or those experiencing
      Superficial abrasion or blistering
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

    Moisture is a chemical cause of pressure
    It weakens the cell wall of individual skin
      It can also change the pH of the skin.
Causes of Skin Damage:
Pressure, Shear, Friction, Moisture

            Sources of moisture:
        Fecal and urinary incontinence,
               Wound drainage,

            Respiratory secretions,

                    Emesis

                  Perspiration
Skin Safety: Risk Assessment
         ALL patients require a
risk assessment at time of admission and
             every 24 hours.
Factors Increasing Risk
   Advanced Age: decreased elastic fibers.
More than 50% of pts with pressure sores >70
         Decreased sensory perception
 Loss of feeling: need someone to look at feet
          Peripheral Vascular Disease
               Impaired Circulation
             Vasoconstriction drugs
          MI/ Stroke,Trauma/fractures
                    GI bleed
Factors Increasing Risk
           Equipment: pneumoboots
   Spinal Cord injury: (Braces and stabilizing
             Neurological disorders
          Chronic medical conditions:
             diabetes, COPD, CHF
           History of pressure ulcers
If have stage I, 10X greater risk of developing
                   higher stage
               Preterm neonates
         Obesity/ Thin: 30 >BMI< 19
Factors Increasing Risk

      Critical Lab: Prealbumin level
    (reflects Visceral Protein Stores)

        Mild depletion = 10-15
       Moderate depletion = 5-10
        Severe depletion = < 5
    Highest risk factors
   >70 years                 stroke
   impaired mobility         pneumonia
   current smoking           CHF
   low BMI                   fever
   altered mental state      sepsis
   urinary and fecal         hypotension
    incontinence              dry and scaly skin
   malnutrition              history of pressure
   restraints                 ulcers
   cancer                    anemia
   diabetes                  lymphopenia
                              hypoalbuminemia
Skin Safety: Risk Assessment

                 Every 24 hours
(Pressure ulcers can develop within 24 hours of
   insult or take as long as 5 days to present.)

             Change in condition
    (surgery, nutrition, level of mobility, etc)
Skin Safety: Risk Assessment

             Braden scale for patients
                   on the adult units.
                  Braden Q scale for
               on the pediatric units.
Braden Scale
   The Braden score is the total of the
    subcategory scores.
       Sensory Perception
       Moisture
       Activity
       Mobility
       Nutrition
       Friction and Shear
Sensory Perception
    Defined as:
        The ability to respond meaningfully to pressure
         related discomfort.
    Score on scale of 1-4
    1.   Completely limited
            Unresponsive or inability to feel pain
    2.   Very limited
            Sensory impairment, moaning or restlessness
    3.   Slightly limited
            Some sensory impairment, can’t communicate need to
             be turned.
    4.   No limitations
            Has no sensory deficits
        Defined as:
          the degree to which skin is exposed to
        Score on scale of 1-4:
    1.     Constantly Moist
             Sweating, incontinent, noticed each time pt is turned
              or moved.
    2.     Moist
             Often moist, linen changed 1x/ shift
    3.     Occasionally moist
             Extra linen change 1x/day
    4.     Rarely moist
             Skin is usually dry, linen changed routinely
        Defined as:
             the degree of physical activity.
        Score on scale of 1-4:
    1.     Bed fast
               Confined to the bed
    2.     Chair fast
               Ability to walk is almost non-existent, must be assisted
                into chair.
    3.     Walks occasionally
               Short distances, infrequent, most of time in bed or
    4.     Walks frequently
               Walks outside of room 2x/day
               Walks inside of room q 2 hours.
        Defined as:
             the ability to change and control body position.
        Score on scale of 1-4
    1.     Completely immobile
               Not even slight changes in position
    2.     Very limited
               Occasional slight changes in position
               Not able to make significant change independently.
    3.     Slightly limited
               Makes frequent though slight changes
    4.     No limitations
               Makes major & frequent changes independently
        Defined as “usual food intake pattern.”
        Score on scale of 1-4
    1.     Very poor
              Never eats complete meal
              Takes fluid poorly
              NPO/ IV fluids only >5 days
    2.     Probably inadequate
              Rarely eats a complete meal
              Occasionally will take supplement
    3.     Adequate
              Eats ½ of most meals
              Will take supplement if miss meals
              On TPN or adequate tube feedings
    4.     Excellent
              Eats every meal
              Does not require supplements
Friction & Shear
        Score on scale of 1-3
    1.     Problem
             Requires max assist for moving
             Sliding against sheets is impossible
             Frequently slides down in bed
             Agitation leads to almost constant friction
    2.     Potential Problem
             Requires minimal assist for moving
             Skin slides to some extent on sheets
             Occasionally slides down in bed or chair
    3.     No apparent problem
             Moves independently
             Lifts up completely during move
             Maintains good position in bed or chair
Braden Scoring
   Total scores for each subcategory.
   Max score is 23.
   Any score less < 4 (<3 for
    friction/shear) requires an intervention
    based on the subcategory.
   Refer to back of Braden Sheet for
    corresponding interventions.
   Place interventions on care plan.
Interventions: Sensory Perception
       Minimize pressure for All patients
   Consider pressure relieving devices:
       Special bed: Matrix mattresses and Bari-beds
       Z-flow positioning pillows
   Increase mobility and activity status whenever
   Minimally, turn patients every 2 hours
     Encourage weight shifting every
    15 min in chair.
     Reposition every 1 hour if patient is

    unable to do it themselves.
Prevent “Bottoming”
Interventions: Mobility
 *Use lifts and hovermats with
 Turn q 1-2 hours

 Post turning schedule

 Encourage ambulating

outside of the room
at least BID.
Interventions: Activity
   *Use lifts and hovermats with
   Position with pillows to elevate pressure
    points off of the bed.
   Consider physical therapy consult (MD)
Interventions: Moisture
   Implement toileting schedule.
   Cleanse skin gently
       Do not use hot water
       Apply skin barrier after each cleansing
       Protect skin with duoderm
   Contain urine, stool, wound drainage, etc.
   Keep skin folds dry.
Interventions: Friction & Shear
   Use transfer devices
   Use minimum of 2 people + draw sheet
    to pull pt up in bed.
   Don’t drag the patient
   Keep HOB at or < 30 degrees
   Use trapeze
   Pad skin surfaces (duoderm)
   Nutrition consult
   Offer nutrition supplements
   Monitor Nutrition intake.
   If NPO for > 24 hours, discuss plan with
   Encourage family/friends to bring in
    favorite foods.
   Help patient get out of bed for meals.
Skin Safety: Skin Inspection
     All Patients require full skin
      inspection upon admission:

 Inspect and palpate skin from head to
  Skin Safety: Skin Inspection
             Ask patients about:
 Areas that lack sensation
 Areas of pain
 Location of previous ulcers
        (increases risk of new ulcer)
 Fragile skin, easy bruising
 Medications or medical condition putting

  patient at higher risk for breakdown, ie:
Skin Safety: Skin Inspection
    Re-inspect and palpate ALL patients
     every 8- 24 hours.
    Re-inspect when transferring between
    Re-inspect after long procedures, ie:
     dialysis, MRI’s, etc.
    Skin Safety: Skin Inspection
Examples of Ways to Integrate Inspection into Assessment:

   When applying O2; check the ears for pressure areas from tubing
If patient is immobile; check the back of the head during repositioning.
When doing lung sounds or turning; look over the back, shoulders and
      When checking bowel sounds; look over skin folds and hips
        When placing pillows under calves; check heels and feet.
             When checking IV sites; check elbows and arms
   If patient is here for surgery; know the areas prone to breakdown.
  When getting patient up or doing cares; check the back, sacrum and
Skin Safety: Skin Inspection
       The Language of Wounds
    Measure wounds upon admission and
     weekly (or with significant changes).

    Note the location, size, depth, color of
     wound bed and surrounding tissue and
            describe the drainage.
Skin Safety: Skin Inspection
  Measure length, width and depth of
  Measuring tools are available in unit

    Describe wound as a clock with
 patient’s head at 12:00 and their feet at
      6:00 to promote consistency in
    Skin Safety: Skin Inspection
                Color of wound bed:
   Pale pink, pink (granulating tissue), red,
    yellow (slough), green (infection?) or black
    (necrotic tissue)
   Intact wound margins or evidence of
    undermining or tunneling.
   Describe the peri-wound skin also.
       (Warm or red may indicate infection. Maceration
        may indicate wound drainage is not managed. )
   Percentage of granulation tissue present
       “75% necrotic tissue with 25% granulation tissue”

Periwound Skin
    Edema
    Induration
    Erythema
    Periwound Pain
    Maceration

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